Cardiology quiz 2

inadequate oxygen delivery to the body tissues results in shock, which may lead to organ failure and death

• - poor blood flow
• - inadequate distribution of flow

Catecholamines, renin, antidiuretic hormone, glucagon, cortisol, and growth hormone

• - hypovolemic shock
• - cardiogenic shock
• - obstructive shock
• - distributive shock

Hemorrhage, loss of plasma, or loss of fluid and electrolytes resulting in decreased intravascular volume. Obvious loss or “third spacing”

May arise from MI, dysrhythmias, CHF, defects in valve, septum ,HTN, myocarditi

Tension pneumothorax, pericardial tamponade, obstructive valvular disease, and PE

From poorly regulated distribution, IE septic shock, systemic inflammatory response syndrome, anaphylaxis

septic shock, associated with ram negative sepsis in people with extreme age, DM, immunosuppression

• Cool extremities
• Weak "thready" distal pulses
• Altered mental status
• Diminished urinary output
• Extremely morbid!! 50% of pts die
• Hypotension
• Absence of hypovolemia
• Poor tissue perfusion: cyanosis, oliguria

• - CBC
• - electrolytes, glucose, urinalysis, and serum creatinine will help determine cause of shock
• - O2 sat, ABG
• - EKG
• - CXR
• - cardio biomarkers (troponin, BNP)
• - lactate levels elevated 

• -BLS (airway, breathing, circulation)
• - Trendelenburg or supine —- blood to the brain!
• - O2, IV access
• - Inotropes - dobutamine, epinephrine,
• - Pressers — dopamine and phenylephrine
• - Fluid resuscitation — unless pulmonary edema is present!

- Insufficient peripheral vasoconstriction in response to orthostatic stress

• - Defined as: drop in BP within 3 mins of standing (20/10 rule):
•    - Systolic bp drop >20
•    - Diastolic bp drop >10

• - reversible 
• -falls

• - A positional drop in BP between supine, sitting and standing
•        -If HR increased by 15 bpm of more you should suspect a blood volume issue/cause
•       - 20/10 rule
•       - If no change in pulse; consider meds, ANS (parkinsons or peripheral neuropathies)

• - CBC
• - CMP
• - EKG
• -tilt test

• - Low cardiac output
• - Cardiac dysrhythimas
• - Low blood volume
• - MedsHemorrhage
• - Excessive diuresis
• - Addison's disease
• - GI illness —> excessive puking and diarrhea = syncope

• - Fluid
• - Med change
• - Monitor

• - Abrupt withdrawl of sympathetic tone that increased parasympathetic tone
• - Main trigger: orthostatic stress (standing), or cough/laugh

- this is the most common type of neural mediated syncope (NMS)

• 1) vasovagal
• 2) situational
• 3) carotid sinus hypersensitivity

• - commonly described using bedzold-jarisch reflex model (entricular mechanoreceptors respond w/ increased discharge-- overshoots as blood is pooling in legs and hands→ kicks off BJ reflex)
• - heart rate and BP drop together is vasovagal!

• -nausea, diaphoresis, tachycardia, pallor
• -aborted by lying down or removing stimulus

- tilt table

• -maintaining adequate hydration
• -avoid predisposing situations

• - An infection of an endocardial surface of the heart
• - Uncommon disease with significant morbidity (20% mortality)

• - Fever (may not be present in elderly)
• - Cough, dyspnea, arthralgias, flank pain and GI symptoms
• - Stable murmur
• - Petechiae, splinter hemorrhages, osler nodes, janeway lesions and roth spots  
• - Pallor and splenomegaly

HF, stroke, systemic embolization and sepsis

-strep, staph, enterococci

staph

• -staph
• - gram neg. organisms 
• - fungi
• - strep in later disease

• - strep virdans 
• - fungi/yeast

• - The valves do not have blood supply
• - WBC cannot reach the valves making them prone to infection
• - Infectious organisms attach to valve surfaces and form vegetations, particularly if the valves are damaged

red raised lesions on hands and feet

retinal hemorrhages with white or pale centers

non-tender!, small, erythematous or hemorrhagic macular or nodular lesions on the palms or soles only a few mm in diameter

• acute: 
•  - symptom onset within 1 wk
• - shaking chills
• - high fever
• - acute malaise
• - normal gamma globulins
• - leukocytosis
• - + rheumatoid fever 

• subacute: 
• - symptom onset 4 wks
• - weight loss
• - night sweats
• - elevated gamma globulins
• - + rheumatoid fever

• - Blood cultures - 3 sets at least 1 hour apart
• - Echo!! - essential to identify what valve is involved (TEE can be useful)
• - Cxr -may show cardiac abnormality or pulmonary infiltrates (if right sided heart)
• - Ekg
• - Dukes criteria

• Duke’s criteria!
• 2 major
• 1 major + 3 minor
• 5 minor
• major
• 1. 2 positive blood cultures of typical causative agent
• 2.echocardiogram evidence of endocardial involvement
• 3.new valvular regurgitation murmur

• minor
• 1.Fever over 100.4
• 2.Vascular phenomena
• 3.Immunologic phenomena (osler nodes, roth spots)
• 4.Positive blood cultures not meeting major criteria

- Empiric abx treatment to cover staph,strep and eneterococci. -vanco w/ ceftriaxone

-If HF: gentamicin, vanco, cefipime

- Abx prophylaxis in patients with invasive dental work-- amoc, clindamycin, cephalexin or azithromycin if allergic

-valve replacement (aortic!) if abx fail of for fungal cause.

• - inflammation of the pericardial sac
• - Disorder involving the pericardium
• - Idiopathic with presumed viral etiology is most common in USA!

• - Chest pain (sharp, dull)
• - Location - precordial or retrosternal and may be referred to trapezius ridge
• - Worse with inspiration
• - Better sitting forward
• -Viral— pts may note prodrome of symptoms of a viral illness!
• - Bacterial - pt may have high fever, chills, night sweats and dyspnea
• - Pericardial friction rub — scratchy

• - 90% idiopathic or due to viral infection → coxsackie, EBV, paroviris, HIV
• -also bacterial infection: TB(africa), staph, strep
• - autoimmune/connective tissue disease, neoplasm, radiation therapy, chemotherapy, drug toxicity , cardiac surgery, tb
• -common in men younger than 50
• -causes pericardial effusion (secondary) that causes restrictive pressure on the heart

• - constrictive pericarditis
• - post MI pericarditis

presents with slowly progressive dyspnea, fatigue and weakness accompanied by edema, hepatomegaly and ascites.

(Dressler syndrome) pt will have recurrence of chest pain w/ presence of audible rub

• - elevated WBC indicates infection= blood and pericardial fluid cultures!
• - post - MI pericarditis shows high sedimentation rate (ESR,CRP, troponins)
• -CXR shows cardiac effusion if 250mL and over
• -ECG changes ST-segment elevation diffuse!
• -Doppler ultrasonography, CT and MRI may be helpful for accurate diagnosis before invasive procedure

• - if hemodynamic compromise, pericardiocentesis is necessary to relieve fluid accumulation.
• - If recurrent effusions= pericardial window.
• - if only inflammatory = NSAIDS
• - infectious conditions= antibiotic therapy (if bacterial)
• - pericardiectomy may be performed to relieve constrictive pericarditis

excess fluid in the pericardial sac, leading to compromised ventricular filling and decreased cardiac output

• -dyspnea
• - Chest discomfort
• - Unconscious and signs of shock
• - Tachycardia/tachypnea
• - More comfortable sitting forward
• - + friction rub with associated pericarditis
• - Pulsus paradoxus - abnormally large decline (>10) in systolic artery pressure with inspiration
• - Jugular venous pressure
• - The 3 D’s: Distant heart sounds, Distended neck veins, Decreased pulse pressure
• - Becks triad: Hypotension, Muffled heart sounds, JVD

• - EKG
• - CXR — small effusions, normal/large effusion - Echo — shows effusion and determines increased intrapericardial pressures
• - Cardiac cath

pericarditis , bleeding into pericardial space after a trauma/surgery

• - Subxiphoid percutaneous pericardiocentesis  - Drainage of pericardial fluid
• - Complications: puncture RV because of anterior position

• - secondary to pericarditis, uremia or cardiac trauma.
• - Produces restrictive pressure on the heart.
• -frequently w/ lung cancer

• - Related to volume of effusion and rapidity of accumulation
• - None-mild with large volumes that accumulate at slow pace (1-2L usually, accidentally found on CXR)
• - Severe symptoms with fast collection at smaller volumes - Increased intra-pericardial pressures
• - Life threatening hemodynamic compromise

• - May compress surrounding structures
• - Dysphagia
• - Cough
• - Hoarseness
• - Hiccups
• - Fullness feeling
• - Nausea
• - Ewart sign: left lower lobe dullness

• - Cardiac tamponade
• - Tachycardia
• - Chest pain
• - Shock

• - EKG - small = normal , large = electrical alternans
• - CXR - large = increased cardiac silhouette
• - Echo - fastest & most accurate dx in pericardial effusions  

- treat underlying cause, pericardiocentesis if effusion is large

• - also called primary HTN 
• - HTN (BP > 140/90)  with no identifiable cause

• - genetic predisposition
• - high sodium diet
• - obesity
• - increased age
• - blacks

• - asymptomatic, until complications develop
• - headache

• - urinalysis 
• - BUN/creatinine, electrolytes 
• - EKG -- may reveal left ventricular hypertrophy

• - lifestyle modifications: weight loss, exercise, diet, decrease salt intake)
• - ACEI's, BB, CCBs, diuretics ("ABCD")

- HTN due to an identifiable cause

• - renal
• - endocrine
• - estrogens, NSAIDS
• - sleep apnea

• "CHAPS"
• - Cushing syndrome, Hyperaldosteroneism, Aortic coactation, Pheochromocytoma, Stenosis of renal arteries

• - BP > 160/100
• - asymptomatic
• - headache
• - evaluate for end organ damage!

• - EKG - showing LV hypertrophy
• - CXR - may show cardiomegaly 
• - decreased hemoglobin or hematocrit 
• - urinalysis 
• - "ABCD"

- most often seen in the elderly

• - "ACS"
• Angina, CHF, Syncope

- pulsus parvus et tardus (weak, delayed carotid upstroke) and a single split S2 sound; systolic murmur radiating to the carotids

• - Harsh systolic ejection crescendo-decrescendo murmur at the right upper sternal border (aortic area) with radiation to the neck and apex heard best by leaning forward with expiration 
• - often loud with a thrill 

- results in the volume overloading caused by the retrograde blood flow into the left ventricle

• - soft early diastolic blowing murmur along left sternal border with pt sitting leaning forward after exhaling 
• - high pitch blowing

- impedes blood flow between right and left atrium

- diastolic low pitched decrescendo rumbling murmur with opening snap heard best at the apex (mitral area) with pt in lateral decubitus position 

primarily secondary to rheumatic fever or chordae tendinae rupture after MI

Holosystolic high-pitched blowing murmur at apex (mitral area) that radiates to axilla with a split S2

harsh, loud, medium pitched systolic murmur heard best at the 2nd/3rd left intercostal space (pulmonic area) that may decrease with inspiration

high pitched, early diastolic decrescendo murmur at the LUSB (pulmonic area) that increases with inspiration 

diastolic rumbling murmur at the LLSB (tricuspid area) with an opening snap

high pitched holosostolic murmur at LLSB (tricuspid area) radiates to the sternum and increases with inspiration 

• - Second most common
• -an opening between the right and left atria. (ostium secundum)

• -systolic ejection murmur at 2nd LICS, early to middle systolic rumbe
• -failure to thrie, fatigability, RV heave, wide fixed split S2

ECG, echocardiography, doppler ultrasonography, MRI, chest radiography, radionuclid flow stdies, cardiac catheterization, angiography

Early surgical repair.

- Extracorporeal membrane oxygenation and alprostadil (prostaglandin E) to maintain a patent ductus can be helpful in stabilizing infants w/ cyanotic

systolic LUSB and left interscapular area- may be continuous

• - infants may present with CHF, older children may have systolic hypertension or mumur or underdeveloped lower extremities
• - Differences between arterial pulses and blood pressure in UE and LE pathognomonic

- 12-15% of significant congenital heart disease- higher in pre-mes

-continuous (machinery) murmur in patients with isolated PDA]

-wide pulse pressure, hyperdynamic apical pulse

-6-10% of significant congenital heart defects

- Ventricular septal defect, aortic origination over the defect, right ventricular outflow obstruction and right ventricular hypertrophy

- Crescendo-decresendo holosystolic at LSB, radiating to back

-cyanosis, clubbing, increased RV impulse at LLSB, loud S2

-polycythemia usually present

-extreme cyanosis, hyperpnea & agitation = medical emergency

- Most common

-systolic murmur at LLSB, others depend on severity of defect

- Depends on size of defect, asymptomatic to signs of CGF

-outlet VSDs common in japan and china